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The Challenges of Teaching Ambulatory Internal Medicine: Faculty Recruitment, Retention, and Development: An AAIM/SGIM Position Paper

Published:October 01, 2016DOI:https://doi.org/10.1016/j.amjmed.2016.09.004
      Perspectives Viewpoints
      • Teaching learners in the ambulatory setting is an important element in both the undergraduate and graduate medical education settings.
      • Difficulty in recruiting and retaining ambulatory clinician educators is widely reported.
      • A model is proposed that includes compensation and incentives, career and faculty development, attention to mentorship, and innovative clinical learning models.
      Ambulatory learning in a general medicine setting is an essential element in undergraduate and graduate medical education. The majority of health care in the United States is provided in ambulatory venues, and the Affordable Care Act is further expanding this trend. According to MedPAC, inpatient admissions decreased 7.8% per Medicare beneficiary from 2004 to 2011, whereas outpatient volume increased 33.6%.

      Vesley R. The great migration. Hospitals & Healthcare Networks, March 11, 2014. Available at: http://www.hhnmag.com/articles/5005-the-great-migration. Accessed March 18, 2016.

      This transition in settings of care will almost certainly continue. At the same time, medical education has undergone its own transformation. The Carnegie report in 2010 called for better longitudinal exposure to illness and standardization of learning outcomes.
      • Irby D.M.
      • Cooke M.
      • O'Brien B.C.
      Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010.
      The Accreditation Council for Graduate Medical Education Next Accreditation System includes increased ambulatory training requirements and the need for competency assessment. With a shift in care delivery and pedagogy, high-quality student and resident education depend on a qualified and robust ambulatory faculty workforce capable of providing and teaching efficient, high-value medical care. However, expansion in this setting is difficult when the current ambulatory faculty workforce is declining.
      Difficulty in recruiting and retaining clinical faculty to teach learners is widely reported.
      • Barzansky B.
      • Jonas H.S.
      • Etzel S.I.
      Educational programs in US medical schools, 1997-1998.
      • Kumar A.
      • Kallen D.J.
      • Mathew T.
      Volunteer faculty: what rewards or incentives do they prefer?.
      • Denton G.D.
      • Grifin R.
      • Cazabon P.
      • et al.
      Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.
      Data from the 2010 Association of Program Directors in Internal Medicine survey demonstrate that greater than 40% of programs reported difficulty recruiting core ambulatory faculty and training them in competency-based assessment.
      • Willet L.L.
      • Estrada C.A.
      • Adams M.
      • et al.
      Challenges with continuity clinic and core faculty accreditation requirements.
      Ambulatory faculty members are subject to multiple competing interests, including clinical access needs, administrative and financial requirements, and time limitations. Mechanisms to recruit and retain talented faculty to teach and mentor learners, including the provision of salary support, job security, academic advancement, and ongoing faculty development, must be addressed.
      A group of ambulatory teachers and educational leaders were assembled by the Alliance for Academic Internal Medicine and the Society for General Internal Medicine to focus on how to engage and support talented faculty in ambulatory education. This group met via teleconference to discuss, prioritize, and map concepts regarding optimal features of ambulatory education in the undergraduate and graduate setting. A literature review was conducted, as well as interviews of 4 general medicine division chiefs and 14 clerkship and program directors.

      Defining the Problem

      Workload and Stress

      Even in practices expressly focused on teaching, workload, and stress related to clinical volume, time, patient complexity, and modernization (particularly electronic health record requirements) will continue to escalate. As high-functioning patient-centered ambulatory practices are developed, improving patient access is important but sometimes conflicts with the education mission. For example, altering faculty schedules to accommodate learners can adversely affect patient access. The markedly increased documentation use review requirements add to physician workload.
      • Ashar B.
      • Levine R.
      • Magaziner J.
      • Shochet R.
      • Wright S.
      An association between paying physician-teachers for their teaching efforts and an improved educational experience for learners.
      The introduction of electronic health records (with attendant dramatic increases in required documentation) has decreased face-to-face time with patients, increased burnout, and decreased levels of professional satisfaction.
      • Gregory S.T.
      • Menser T.
      Burnout among primary care physicians: a test of the areas of worklife model.
      • Bodenheimer T.
      • Sinsky C.
      From triple to quadruple aim: care of the patient requires care of the provider.
      An electronic health record survey of continuity clinic residency directors also demonstrated that residents and clinic directors experience significant distress because of the high proportion of medically and socially complex patients in their continuity clinics.
      • Nadkarni M.
      • Reddy S.
      • Bates C.K.
      • et al.
      Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors.
      Redesign of care systems, including patient-centered medical homes, improves processes and outcomes of patient care and should provide optimal models to expose learners to the best possible patient care. However, transformations in care systems must be aligned with transformation of the people involved.
      • Ruddy M.P.
      • Thomas-Hemak L.
      • Meade L.
      Practice transformation: professional development is personal.
      Until alignment has fully occurred, teaching physicians on the front lines of change will experience increased stress. Organizational changes that increase workload without a concomitant restructuring of resources lead to a decrease in physician engagement and higher levels of burnout.
      • Linzer M.
      • Levine R.
      • Meltzer D.
      • et al.
      10 bold steps to prevent burnout in general internal medicine.
      The changes not only provide a suboptimal experience for learners but also weaken the workforce that needs to be expanded. It is critical that program design and curricular innovations are structured with consideration of the need to offset noneducational requirements of participating faculty.

      Inadequate Financial Support

      Funds to support graduate medical education and undergraduate medical education are often limited. Even when adequate funds are available, the intentional use of these monies to prioritize ambulatory education may not occur. Graduate medical education funds often do not flow through the hospital to the training program.
      • Fitzgibbons J.P.
      • Bordley D.R.
      • Berkowitz L.R.
      • Berkowitz L.R.
      • Miller B.W.
      • Henderson M.C.
      Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.
      Likewise, funds for medical student teaching do not always support their intended target. Despite the need to train more learners in the ambulatory setting, most managed care organizations, regardless of their role in influencing the pace of this shift, bear no responsibility for the costs of the teaching.
      • Bowen J.L.
      • Irby D.M.
      Assessing quality and costs of education in the ambulatory setting: a review of the literature.
      Without these funds, nonsalaried volunteer faculty in the community and salaried academic educators have to meet the requirement for educating learners in the clinic setting. Learners in the clinic decrease productivity of the faculty when measured in patient volume and billing ability, placing individual faculty compensation at risk.
      • Ellis J.
      • Alweis R.
      A review of learner impact on faculty productivity.

      Increased Demand for Ambulatory Training

      Interviews with internal medicine residency program and clerkship directors identified increased competition for limited training sites as a major challenge. First, the recognition that earlier clinical exposure has educational value means that preclinical medical students now also need space. Second, many noninternal medicine resident and nonphysician learner training requirements include ambulatory experiences in internal medicine; integrating these learners adds additional demands for space. Third, in the interest of advancing team-based care and fostering care teams that deliberately work together, learners are increasingly required to train in an interprofessional environment. Many programs have welcomed pharmacy, psychology, social work, and other students into their clinical learning environments. This influx of learners, combined with a declining number of practicing ambulatory internists, has created intense competition for high-quality outpatient clinical learning environments.

      Inadequate Faculty Development

      The need for ambulatory general internal medicine education requires a large number of faculty preceptors, but most have little prior experience in teaching or assessment. With the move to clinical competency assessment in undergraduate medical education and graduate medical education, all ambulatory faculty will require instruction. Asking faculty to teach and assess without opportunities for learning the necessary skills increases stress, decreases satisfaction, and may adversely affect retention of ambulatory internists as teachers. Faculty development not only improves teaching effectiveness
      • Steinert Y.
      • Mann K.
      • Centeno A.
      • et al.
      A systematic review of faculty development initiatives designed to improve teaching effectiveness in medical education: BEME guide no. 8.
      but also can provide strategies that make teaching more rewarding and may minimize the rate of faculty attrition. Faculty development has been shown to be integral to faculty retention.
      • Osborn L.M.
      • Sostok M.
      • Castellano P.Z.
      • et al.
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      A robust program of faculty development ensures a competent clinician educator workforce and creates effective role models, clinical supervisors, and mentors.

      Proposed Solutions

      Provide Adequate Time and Compensation

      Medical student teaching in the outpatient setting requires extra time, up to 32 minutes per half-day clinic per student.
      • Denton G.D.
      • Durning S.J.
      • Hemmer P.A.
      • Pangaro L.N.
      A time and motion study of the effect of ambulatory medical students on the duration of general internal medicine clinics.
      Preceptors who work with students and residents generally do not reduce their clinical volume to account for time to teach, but extend their day by 30 to 50 minutes per half-day of clinic when working with learners,
      • Bowen J.L.
      • Irby D.M.
      Assessing quality and costs of education in the ambulatory setting: a review of the literature.
      shifting the impact to personal and family time. To attract and retain talented ambulatory teachers, faculty must have protected time to teach. Departments should implement workflow adaptations to deliberately identify and protect teaching time, such as the use of scribes, which have been shown to increase clinician productivity and efficiency,
      • Gellart G.A.
      • Ramierez R.
      • Webster S.L.
      The rise of the medical scribe industry: implications for the advancement of electronic health records.
      or offsetting reductions in patient access by using advanced practice providers.
      Although clinician-educators tend to be tremendously altruistic, it is unreasonable to expect faculty to be rewarded solely by the notion of contributing to the success of future generations. Losses in productivity income should be balanced by use of federal direct medical education funding or tuition so that agreeing to teach does not result in a net loss in compensation. Paying faculty to teach is positively correlated with teacher evaluations.
      • Ashar B.
      • Levine R.
      • Magaziner J.
      • Shochet R.
      • Wright S.
      An association between paying physician-teachers for their teaching efforts and an improved educational experience for learners.
      There is little literature available on the effect of enhanced compensation models on faculty satisfaction, but it is clear that if more learners are to be encouraged to pursue primary care disciplines, perceived faculty satisfaction is an important variable.
      • Meli D.N.
      • Ng A.
      • Singer S.
      • Frey P.
      • Schaufelberger M.
      General practitioner teachers' job satisfaction and their medical students' wish to join the field – a correlational study.
      An educational relative value unit system to offset clinical productivity losses related to teaching is being used increasingly at both the medical student and resident levels (personal communication, AAIM Listserve 2014).
      • Denton G.D.
      • Grifin R.
      • Cazabon P.
      • et al.
      Recruiting primary care physicians to teach medical students in the ambulatory setting: a model of protected time, allocated money, and faculty development.
      • Osborn L.M.
      • Sostok M.
      • Castellano P.Z.
      • et al.
      Recruiting and retaining clinician-educators. Lessons learned from three programs.
      In one center, the introduction of an educational relative value unit model allowed a residency program to more equitably distribute the teaching load and create a greater number of full-time equivalents dedicated to teaching.
      • Yeh M.M.
      • Cahill D.F.
      Quantifying physician teaching productivity using clinical relative value units.
      The challenges of funding ambulatory education are formidable, particularly because redistribution of teaching funds may be required. At the undergraduate level, a review of the methodologies used to allocate teaching dollars would be a useful way to share best practices. At the residency level, it may be time to call on institutional graduate medical education sponsors to provide support. The current move to accountable care payment structures might provide unique opportunities for funding ambulatory education; in addition, managed care organizations should begin to assume some responsibility for this important cost.

      Make Career Development for Ambulatory Educators an Institutional Focus

      A paradigm shift is needed in the way faculty are promoted and recognized.
      • Fitzgibbons J.P.
      • Bordley D.R.
      • Berkowitz L.R.
      • Berkowitz L.R.
      • Miller B.W.
      • Henderson M.C.
      Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.
      Academic faculty face pressures to compete for external funding and publish in peer-reviewed journals to be promoted, even when their highest value to an educational institution is direct work with learners.
      • Fitzgibbons J.P.
      • Bordley D.R.
      • Berkowitz L.R.
      • Berkowitz L.R.
      • Miller B.W.
      • Henderson M.C.
      Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.
      Promotion criteria must value teachers for advancing the educational mission, including recognition of curriculum development, teaching portfolios, mentoring activities, educational presentations, evaluations by learners, and awards. Teaching excellence should be measured and rewarded.
      • Bowen J.L.
      • Salerno S.M.
      • Chamberlain J.K.
      • et al.
      Changing habits of practice. Transforming internal medicine residency education in ambulatory settings.
      One proposed core faculty model calls for a group of master educators who are provided resources and salary support for education.
      • Weinberger S.E.
      • Smith L.C.
      • Collier V.U.
      Redesigning training for internal medicine.
      In 2006, the Association of Program Directors in Internal Medicine called for a “renewed commitment to teaching by departments of medicine and their faculty,”
      • Fitzgibbons J.P.
      • Bordley D.R.
      • Berkowitz L.R.
      • Berkowitz L.R.
      • Miller B.W.
      • Henderson M.C.
      Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.
      including identification of talented faculty and resources to lead educational programs and provide mentorship to learners. The selection process for faculty should be competitive and prestigious
      • Ashar B.
      • Levine R.
      • Magaziner J.
      • Shochet R.
      • Wright S.
      An association between paying physician-teachers for their teaching efforts and an improved educational experience for learners.
      so that enthusiastic role models who focus on clinical excellence are chosen. Institutional recognition in the form of teaching awards is a simple, cost-neutral way to reward this important activity and promote excellence; however, awards will not be sufficient without appointment and promotion criteria that value teaching.

      Implement Effective Models of Faculty Development

      The need for faculty development for learner preceptors in the ambulatory setting has been long recognized.
      • Bowen J.L.
      • Irby D.M.
      Assessing quality and costs of education in the ambulatory setting: a review of the literature.
      • Weinberger S.E.
      • Smith L.C.
      • Collier V.U.
      Redesigning training for internal medicine.
      Clinicians traditionally are confident in their clinical practice but less so in their skill as educators.
      • Weinberger S.E.
      • Smith L.C.
      • Collier V.U.
      Redesigning training for internal medicine.
      The introduction of milestones and competency-based medical education in both undergraduate medical education and graduate medical education requires new skill sets to mirror changes in the educational paradigm.
      • Holmboe E.S.
      • Ward D.S.
      • Reznick R.K.
      • et al.
      Faculty development in assessment: the missing link in competency-based medical education.
      Internal medicine has historically led national efforts to prepare teachers in the ambulatory setting. In 1999, the faculty development program “Generalist Faculty Teaching in the Ambulatory Settings” trained 110 teams from 57 university-based and 53 community-based hospitals.
      • Bowen J.L.
      • Clark J.M.
      • Houston T.K.
      • et al.
      A national collaboration to disseminate skills for outpatient teaching in internal medicine: program description and preliminary evaluation.
      Fifty-nine of the teams implemented local faculty development projects and trained more than 1400 faculty, of which approximately 500 were community-based.
      • Houston T.K.
      • Clark J.M.
      • Levine R.B.
      • et al.
      Outcomes of a national faculty development program in teaching skills: prospective follow-up of 110 medicine faculty development teams.
      One challenge of faculty development is finding a way that realistically allows time sufficient for meaningful engagement. Faculty development workshops can be dual purposed; clinicians can gain clinical skills at the same time they are developing and practicing teaching skills.
      • Green M.L.
      • Gross C.P.
      • Kernan W.N.
      • et al.
      Integrating teaching skills and clinical content in a faculty development workshop.
      High-value care and quality improvement may represent ideal content opportunities for this type of venue. Workplace faculty development models, based on the theory that learning should take place in context, have been proposed.
      • O'Sullivan P.S.
      • Irby D.M.
      Reframing research on faculty development.
      • Silver I.L.
      • Leslie K.
      Faculty development for continuing interprofessional education and collaborative practice.
      • Clay M.A.
      • Sikon A.L.
      • Lypson M.L.
      • et al.
      Teaching while learning while practicing: reframing faculty development for the patient centered medical home.
      Departmental and divisional leadership must support protected time for ongoing faculty development.

      Recruit and Retain with Faculty Mentorship in Mind

      Critical to the success of faculty development in any venue is the content and design of its faculty mentorship program. An Association of Program Directors in Internal Medicine position article on educational redesign emphasized the need for qualified clinician-educators to lead faculty development and provide mentorship to junior teaching faculty,
      • Fitzgibbons J.P.
      • Bordley D.R.
      • Berkowitz L.R.
      • Berkowitz L.R.
      • Miller B.W.
      • Henderson M.C.
      Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.
      including peer observation of teaching and assessment. Many institutions are creating communities of educators for purposes of faculty development and to provide camaraderie and opportunities for career enhancement. Developing a culture of collegiality and an emphasis on faculty collaboration and mentorship is a strategy that resounded in phone interviews. Although rigorous research on mentorship is limited, one systematic review of 39 faculty mentoring programs did find positive influences on personal development, research productivity, faculty retention, and career guidance, especially in the realm of medical education.
      • Sambunjak D.
      • Straus S.E.
      • Marušić A.
      Mentoring in academic medicine: a systematic review.
      Several elements were key to programmatic success: mentor engagement, program steering committees, mentor–mentee relationships, formal curricula, regularly scheduled mentoring activities, and dedicated program funding. The Association of American Medical Colleges catalog of 16 successful mentoring programs can provide further guidance for other academic institutions to create similar faculty programs for career and leadership development.

      Medical School Based Mentoring Programs. Available at: https://www.aamc.org/download/53332/data/mentoringprograms10.pdf. Accessed April 30, 2016.

      Use Innovative Clinical Learning Models

      Many programs have begun to create innovative educational models. Examples include longitudinal integrated clerkships or the medical subspecialties in longitudinal block models in residency programs. Some training sites have combined general medicine with other primary care specialties; others have incorporated more outpatient-based subspecialties to balance the training experience.
      • Harrison J.W.
      • Ramaiya A.
      • Cronkright P.
      Restoring emphasis on ambulatory internal medicine training-the 3∶1 model.
      Integrating students into resident clinics also can be a useful strategy. Use of nontraditional academic environments, such as community health clinics, clinics for the homeless, or clinics within prisons, is another approach that can expand the preceptor pool and expose learners to a diverse set of clinical experiences.
      Several residency programs have implemented ambulatory long block models
      • Warm E.J.
      • Schauer D.P.
      • Diers T.
      • et al.
      The ambulatory long-block: an Accreditation Council for Graduate Medical Education (ACGME) Educational Innovations Project (EIP).
      associated with improved resident, faculty, and patient satisfaction, as well as continuity. In addition, increased adoption of “X + Y” models that alternate 1- to 2-week clinic blocks every 3 to 6 weeks better incorporate residents into the clinic environment while minimizing conflicting inpatient responsibilities.
      • Nadkarni M.
      • Reddy S.
      • Bates C.K.
      • et al.
      Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors.
      • Steinman F.
      A new era for residency training in internal medicine.
      The transition to 1 model (4 + 1) was associated with an increase in resident satisfaction and continuity and a significant decrease in stress; faculty also found it beneficial.
      • Chaudhry S.I.
      • Balwan S.
      • Friedman K.A.
      • et al.
      Moving forward in GME reform: a $ + ! model of resident ambulatory training.
      At the undergraduate level, an “education-centered medical home” is an innovative strategy that embeds student teams of near-peer learners into a faculty practice with a high-risk patient panel. Both faculty and student satisfaction with this model have been high.
      • Henschen B.L.
      • Garcia P.
      • Jacobson B.
      • et al.
      The patient centered medical home as curricular model: perceived impact of the “education-centered medical home”.
      The formation of learning collaboratives has recently demonstrated engagement benefits in several ambulatory settings
      • Nordstrom B.R.
      • Saunders E.C.
      • McLeman B.
      • et al.
      Using a learning collaborative strategy with office-based practices to increase access and improve quality of care for patients with opioid use disorders.
      • Warm E.J.
      • Logio L.S.
      • Pereira A.
      • Buranosky R.
      • McNeill D.
      The Educational Innovations Project: a community of practice.
      and may be a useful method of addressing issues around faculty satisfaction and retention.

      Cater to the Specific Clinical and Educational Interests of Ambulatory Faculty

      Ambulatory faculty members enjoy academic activities that align with their clinical interests; harnessing this passion will engage faculty in ambulatory education. Specialized clinics that operate out of divisions of general medicine

      HIV/AIDS. Available at: http://www.montefiore.org/hiv-aids. Accessed June 20, 2016.

      • Wittich C.M.
      • Ficalora R.D.
      • Mason T.G.
      • Beckman T.J.
      Musculoskeletal injection.
      • Miller L.
      • Fluker S.A.
      • Osborn M.
      • Liu X.
      • Strawder A.
      Improving access to hepatitis C for urban, underserved patients using a primary care-based hepatitis C clinic.
      • Lo M.C.
      • Freeman M.
      • Lansang M.C.
      Effect of a multidisciplinary-assisted resident diabetes clinic on resident knowledge and patient outcomes.
      serve as prime educational opportunities for learners to be taught by ambulatory clinician educators in specific areas not addressed in traditional primary care clinics, provide a nidus for practice-based research, and are frequently associated with improved patient outcomes.
      • Miller L.
      • Fluker S.A.
      • Osborn M.
      • Liu X.
      • Strawder A.
      Improving access to hepatitis C for urban, underserved patients using a primary care-based hepatitis C clinic.
      • Lo M.C.
      • Freeman M.
      • Lansang M.C.
      Effect of a multidisciplinary-assisted resident diabetes clinic on resident knowledge and patient outcomes.
      Such specialized clinics can establish a unified clinical and teaching niche for ambulatory faculty while fostering faculty satisfaction and career advancement.

      Provide Additional Incentives

      Although the availability of direct funds is critical, other means of incentivizing and rewarding faculty who participate in ambulatory education are cost-neutral. In addition to rewarding teaching excellence, the provision of an academic title can be helpful in recruiting faculty and assisting them with career advancement. Allowing faculty who teach to choose clinic/precepting days and providing extra swing rooms are helpful tokens of appreciation. In addition, relatively simple gestures can communicate the value of the educational mission—an annual dinner or retreat, creation of ambulatory teaching awards, a brief letter from the program, or clerkship director to the departmental chair thanking the faculty for their teaching contribution. For volunteer faculty, relatively simple measures such as a free parking space or a dedicated teaching faculty lounge can instill a sense of appreciation for ambulatory teaching.

      Discussion

      Ambulatory medicine is a rapidly growing segment of health care, yet educational changes have not evolved at a similar pace. Changes are necessary with fewer residents and medical students choosing careers in primary care, highlighting the notion that “dysfunctional clinic environments are a key barrier to meaningful ambulatory education.”
      • Nadkarni M.
      • Reddy S.
      • Bates C.K.
      • et al.
      Ambulatory-based education in internal medicine: current organization and implications for transformation. Results of a national survey of resident continuity clinic directors.
      Ambulatory clinician educators are critically important to medical schools and the health care system. The Liaison Committee on Medical Education made ambulatory education a requirement.

      Liasion Committee on Medical Education: Functions and Structure of a Medical School 2017-2018. Available at: http://lcme.org/publications/. Accessed June 15, 2016.

      The Accreditation Council for Graduate Medical Education requires that residents have “clinical experiences in efficient, effective ambulatory and inpatient settings,” with at least one third of the residency training occurring in the ambulatory environment.

      Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Internal Medicine. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_07012015.pdf. Accessed June 15, 2016.

      The implementation of the Affordable Care Act and the anticipated changes to graduate medical education funding are both opportunities to enact meaningful positive changes in the ambulatory education arena, ideally with a redistribution of resources to help achieve this goal. Prioritizing transparency and distributing funds consistently with the values of the ambulatory educational mission has never been more necessary.
      Faculty workload must be offset to recruit and retain qualified educators; quality of life needs to be addressed. Innovation and additional study must be focused on developing methods of making ambulatory education more efficient and feasible. Resources should be redirected to pay for scribes, additional rooms, or the hiring of more advanced practice providers. Creative means of “team teaching” in the ambulatory arena could be explored so that the entire teaching burden is not borne by the faculty.

      Conclusions

      Faculty must be incentivized for participating in medical education and rewarded for excellence. Measurement of only clinical productivity unintentionally devalues education. The broad implementation of an educational relative value unit system or mission-based budgeting can help counteract this unintentional consequence. The creation of a core faculty model could increase efficiency and allow for better learner continuity, as well as the ability to focus faculty development on a smaller group of expert educators. Workplace models of faculty development can be implemented to capitalize on learning in context, and innovative clinical learning models should be explored. Faculty development and incentive models also should include community-based faculty who are frequently key educators of students and residents in ambulatory settings. Future research on the implementation of these approaches will be helpful in defining best practices for the generations of ambulatory teachers to come.

      Acknowledgments

      Contributors: The Alliance for Academic Internal Medicine Board of Directors and the Society for General Internal Medicine Council reviewed and approved the article. The authors appreciate the contribution of Alliance for Academic Internal Medicine for assistance in organizing teleconferences to facilitate development of the article and the Alliance for Academic Internal Medicine and Society for General Internal Medicine for selecting expert authors for the writing group.

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